The Hip Resurfacing Handbook

A Practical Guide to the Use and Management of Modern Hip Resurfacings

K De Smet, P. N. Campbell, C Van Der Straeten

• Publisher: Woodhead Publishing
• Year: 2013
• Print ISBN: 9781845699482
• eBook ISBN: 9780857096203
• Topic: Technology & Engineering
• Subtopic: Biomedical Science
• Index: Technology & Engineering

Hip resurfacing arthroplasty (HRA) using metal-on-metal bearings is an established but specialised technique in joint surgery. Based on the experience of leading experts in the field, The hip resurfacing handbook provides a comprehensive reference for all aspects of this important procedure.The first part of the book reviews and compares all the major hip resurfacing prostheses, their key design features, relevant surgical techniques and clinical results. Part two discusses clinical follow-up of the hip resurfacing patient, including pre- and post-operative examination, acoustic phenomena and rehabilitation. It also covers the use of techniques such as radiography and metal ion measurement, as well as bone scans, ultrasound, CT, MRI, PET and DEXA, to evaluate hip resurfacings. Part three reviews best practice in surgical technique, including the modified posterior and anterior approaches, as well as instrumentation, anaesthesia and revision surgery. Based on extensive retrieval studies, Part four includes examples of the main failure modes in HRA. The final part of the book includes patients' own experiences, a comparison of HRA with total hip arthroplasty (THA), regulatory issues and relevant web sites.Comprehensive in its scope and authoritative in its coverage, The hip resurfacing handbook is a standard work for orthopaedic surgeons and all those involved in HRA.- A standard work for orthopaedic surgeons and all those involved in HRA- Reviews and compares all the major hip resurfacing prostheses, their key design features, relevant surgical techniques and clinical results- Clinical follow-up of the patient is discussed

Part I

Hip resurfacing designs

1

The advanced ceramic coated implant systems (ACCIS) hip resurfacing prosthesis

K.J. Hamelynck and R.G. Woering

Abstract:

The ACCIS (advanced ceramic coated implant systems) hip resurfacing arthroplasty is manufactured in Germany and was introduced in 2004. The ACCIS is made from cobalt chromium alloy, but this design differs from other hip resurfacings by having titanium-niobium-nitride ceramic engineered surfaces to minimize wear, and to prevent corrosion and metal ion release. The components are manufactured by casting followed by heat treatment. The press-fit acetabular component is the same as the total hip socket and has a tri-radial outer geometry, a titanium plasma sprayed coating and de-rotation fins. A cement fixation version of the cup is available. The femoral component is available for cemented fixation. A discussion of the reasons behind the ACCIS design features and a recommended surgical technique are included. The ACCIS ion data appear to demonstrate the effect of the ceramic modification process of the metal surfaces.

Key words

ceramic coating

tri-radial geometry

physical vapor deposition

1.1 Introduction

The advanced ceramic coated implant systems (ACCIS) prosthesis for hip resurfacing arthroplasty (HRA) (Fig. 1.1) is different from all other metal-on-metal (MoM) prostheses designed for HRA: the surfaces of the metal components are engineered with a titanium-niobium-nitride (TiNbN) ceramic to minimize wear, to prevent corrosion and metal ion release. Despite the fact that the original metal-on-metal total hip prostheses, like the McKee-Farrar prosthesis, have demonstrated 10–40 times less wear than metal-on-polyethylene hip prostheses at long-term follow-up (Doorn et al., 1996b) and that modern MoM prostheses demonstrate minimal volumetric wear (Chan et al., 1999; Rieker et al., 2004; Schmidt et al., 1996), minimizing the wear of metal components in MoM hip arthroplasty is still needed.

1.1 ACCIS hip resurfacing system.

It has been found that the number of particles generated in MoM prostheses was considerably higher (7–30 times) than with prostheses with a polyethylene surface and also that these particles are of submicron size: 80 (20–834) nm. Particles of this size may become biologically active (Doorn et al., 1996a; McKellop et al., 1996; Walker et al., 1974; Howie et al., 2005), as they may be stored in histiocytes, which are known to produce osteolytic mediators (Beaulé et al., 2001; Campbell et al., 2004). Wear particles may contribute in the formation of pseudo-tumors (Pandit et al., 2008; Clayton et al., 2008). High levels of chromium and cobalt ions have been found in the blood of patients after MoM hip replacement, and the presence of released metal ions both locally and systemically has been documented (Mabilleau et al., 2008; Whittingham-Jones et al., 2008).

A number of factors affect the release of metal ions. Metal bearings of MoM hip replacement systems corrode at a rate determined by their surface area and cause the release of metal ions (Witzleb et al., 2006). Significantly more wear particles are generated when there is a steep position of the acetabular component, e.g. more than 55° of abduction (De Haan et al., 2008). Free metal particles may contribute considerably to the total surface area of the metal and thus to the release of metal ions. A correlation between the amount of particles within the joint and the amount of metal ions in the blood has been found (De Smet et al., 2008; DeHaan et al., 2008). The metal ions may combine with local proteins within the hip joint, which then can be recognized by the body as foreign proteins resulting in an immune response, including a delayed-type hypersensitivity response with severe reactions of the peri-articular tissues (Campbell et al., 2008; Davies et al., 2005; Hallab et al., 2004; Willert et al., 2005). Apart from the concerns about the local reactions to metal particles and ions, there are also concerns about general consequences. Among the concerns about the general health effects on patients are the fears that these particles and ions may be carcinogenic, mutagenic and teratogenic (Dunstan et al., 2008; Lidgren, 2008). Another concern is that metal ions may cross the placenta of pregnant women after metal-on-metal hip arthroplasty (Ziaee et al., 2007, Brodner et al., 2004).

These concerns about the release of metal ions suggest that minimization of wear and corrosion of metal components in metal-on-metal hip arthroplasty is an important objective. In order to minimize the wear and corrosion of MoM prostheses, the metal surfaces of the ACCIS prosthesis are engineered with the ceramic TiNbN. TiNbN is integrated into the metal surfaces by physical vapor deposition (PVD). The value of PVD technology lies in its capacity to modify the surface properties of a device without changing the underlying material properties and biomechanical functionality. In addition to enhanced wear resistance, PVD coatings reduce friction, are compatible with sterilization processes and improve corrosion resistance (Wisbey et al., 1987; Davis, 2003). If the ceramic is merely a coating, this ceramic may break free, and may cause serious third-body wear. The thicker a coating, the more the ceramic characteristics will become prominent and the less the characteristics of the metal substrate remain (Williams et al., 2003). By the ACCIS method of surface engineering with TiNbN applied by PVD, the ceramic is integrated into the metal, penetrating several atoms deep, thus enhancing the bond strength. It is extremely thin, averaging 0.5 (range 0.3–0.8) microns, and cannot break free. The ceramic TiNbN has the advantage of being extremely hard and very wear resistant. Pre-clinical wear tests performed at various independent institutes support this belief (AEA, 1999; Kremling and Franke 2005a, 2005b). Clinical follow-up studies of the ACCIS prosthesis demonstrate that virtually no change in chromium ion concentrations and a minimal increase in cobalt ion concentrations was found up to two years after implantation of the prosthesis (Hamelynck et al., 2011).

1.2 Information about the Advanced Ceramic Coated Implant Systems (ACCIS) Prostheses

The ACCIS acetabular and femoral components for total hip arthroplasty were introduced in 2001. In 2005 the components for surface replacement were introduced, the acetabular components being identical to the acetabular component for total hip replacement. The p...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Contributor contact details
• Woodhead Publishing Series in Biomaterials
• Acknowledgements
• Preface
• Introduction
• Part I: Hip resurfacing designs
• Part II: Clinical follow-up
• Part III: Operating techniques
• Part IV: Failure modes in hip resurfacing
• Part V: General hip resurfacing issues
• Index